Bronchiolitis, caused by RSV, is an illness of the lower respiratory tract that usually includes wheezing due to inflammation of the small airways of the lungs.
SYMPTOMS
- Congestion
- Sneezing
- Fever
Followed by:
- Wheezing
- Coughing
CAUSES AND TRANSMISSION
This is a viral illness, most commonly caused by the respiratory syncytial virus (hereinafter “RSV”). It is transmitted by people who do not wash their hands after coming in to contact with secretions of a person with the illness. The virus is then transferred to one of a child’s mucus membranes, which are found in the eyes, nose or mouth. Transmission from hands is much more common with this virus than is respiratory transmission. It is more likely to catch this if someone with it touches you than if they cough in your face. Smoking and daycare attendance are risk factors for contracting RSV. If you’re not exposed to RSV, you don’t get it.
DIAGNOSIS
The diagnosis is made by the physician hearing wheezing in the chest of a child who recently caught a cold. Wheezing without a recent history of cold symptoms may be bronchiolitis, but may also be an inhaled foreign body or an asthma exacerbation.
TREATMENT
Treatment includes:
- Fluids
- Humidified air
- Albuterol (Proventil, Ventolin)
- An oxygen mist tent (if hospitalized)
Rarely, virazole (Ribavirin) can be used in children who have underlying heart or lung disease or prematurity.
OUTCOME
Generally good. Almost all children have had RSV by two years of age. Most of them just get a cold or some wheezing. Very few end up in the hospital. Some children don’t survive the infection, but the mortality rate is less than 1%, and is mostly in children with an underlying heart or lung disease, immunodeficiency disease, or in extremely premature infants.
DISCUSSION WITH DR. B
Bronchiolitis, usually caused by RSV, is generally a winter illness that occurs between the months of September and March. Children catch the viral infection by fomite transmission, i.e., a hand covered with the virus contacts a nose, mouth, or eye. Treatment is mostly symptomatic with fluids, humidified air and, in worst cases, oxygen and albuterol. Antibiotics have no effect since this is not a bacterial infection. Children get congestion and/or fever, followed by coughing, wheezing and, in worst cases, by respiratory distress. Respiratory distress includes:
- A respiratory rate of over 60 breaths per minute
- Nasal flaring
- Retracting
Retracting is the sucking in of the abdomen during breathing. When you see retractions in the child, it means the child has to use accessory muscles of respiration to help get air into and out of the lungs.
RSV can be prevented by avoiding exposure, practicing good hand washing rituals, and the use of immune globulin. There are two types of immune globulin: RSVIG (Respi-Gam) and palivizumab (Synagis). RSVIG (Respi-Gam) is given intravenously once a month during the RSV season. Palivizumab (Synagis) is given each year via intramuscular shot each month during the RSV season, from September through March. These medicines are around $1,000 per shot, and are meant only for children at high risk. High-risk children include those under two years of age with heart disease, lung disease, immune deficiency, or severe prematurity.
DR. B’s THOUGHTS
From September to March, I am overwhelmed by the number of wheezing children that come to my office. Sometimes I think I should have a ventilator that blows albuterol into the waiting room! If the wheezing is minimal, I use albuterol syrup. If the wheezing is more severe, I give albuterol by nebulizer or spacer and resort to hospitalization if the child is in respiratory distress after giving two to three albuterol nebulizer treatments in the office. If the child is in the hospital, I will usually put him/her under an oxygen mist tent and administer albuterol treatments. I very rarely use ribavirin, as I have not had good luck with this medication. I will use it in children with heart disease, lung disease, an underlying immunodeficiency, cystic fibrosis or with children who are under a month old.
I do not usually test for RSV unless I admit a child into the hospital or if the parents request it, because knowing that the illness is RSV won’t change my therapy. Most parents just want the cough to stop, but unfortunately, it may linger for weeks. Cough suppressants don’t seem to work.
It’s just a matter of keeping the child comfortable, pushing fluids, using a humidifier, and maybe having the child sleep in a slightly upright position. Basically, like with most viral illnesses, you simply wait for the symptoms to pass. Avoid antibiotics for this illness since it is viral and you will just be dealing with the complications resulting from taking the antibiotics. Most importantly, however, remember that good hand washing is the best way to prevent contracting this illness and the best way to prevent transmitting it to other people.
by Dr. Michael Bornstein, who has over 28 years of experience as a pediatrician.
Disclaimer: The contents of this article, including text and images, are for informational purposes only and do not constitute a medical service. Always seek the advice of a physician or other qualified health professional for medical advice, diagnosis, and treatment.
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